Provider Demographics
NPI:1326213554
Name:KELLY, AMANDA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 HARBOR DR STE 111
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1491
Mailing Address - Country:US
Mailing Address - Phone:415-683-2988
Mailing Address - Fax:415-683-2980
Practice Address - Street 1:1700 CALIFORNIA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4586
Practice Address - Country:US
Practice Address - Phone:415-386-8406
Practice Address - Fax:415-386-5388
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA492432363LF0000X
CAPA14985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP36790Medicare UPIN